2623 Isolated Duodenal Variceal Bleeding Secondary to Metastatic Carcinoid Tumor Obstructing the Superior Mesenteric Vein

Abstract

INTRODUCTION: Gastrointestinal bleeding secondary to duodenal varices is an uncommon finding, and is typically seen in patients with portal hypertension due to cirrhosis. We report a case of a patient without evidence of liver disease who developed significant bleeding from isolated duodenal varices caused by mesenteric venous obstruction from a carcinoid mass. CASE DESCRIPTION/METHODS: A 71-year-old male with a history of a metastatic mesenteric carcinoid tumor presented with recurrent gastrointestinal bleeding. He was initially diagnosed with carcinoid of the mesentery several years prior, for which he underwent resection followed by Y40 ablation of liver metastases. He had been admitted multiple times at a local hospital for recurrent gastrointestinal bleeding, for which he had undergone extensive endoscopic evaluation. He was then transferred to our facility for a higher level of care. A double balloon push enteroscopy and endoscopic ultrasound were performed with findings of a large cluster of bleeding duodenal varices in the third portion of the duodenum not amenable to endoscopic intervention. CT abdomen and pelvis with contrast and CT angiography of the abdomen showed an irregular 3 cm calcified mass at the root of the mesentery. Additionally, several branches of the superior mesenteric artery and vein (SMA and SMV) were noted to be occluded near the mass. Interventional radiology (IR) performed an IR-guided transhepatic portogram revealing obstruction of the SMV at the level of the mesenteric mass. There appeared to be a large colic branch communicating with an abnormal cluster of varices near the third portion of the duodenum. Two overlapping covered stents were placed at the large colic branch into the SMV, decompressing the varices. The patient was started on plavix, propranolol, and octreotide depot and safely discharged home without further bleeding. DISCUSSION: Duodenal varices are an uncommon but potentially serious complication of portal hypertension, and are most often seen as a sequelae of liver disease. The development of duodenal varices as a result of venous obstruction secondary to a desmoplastic reaction induced by a carcinoid tumor has seldom been reported in the literature. This case illustrates a noteworthy example of bleeding ectopic varices in a patient without liver disease, a rare cause of obscure gastrointestinal bleeding.